Provider Demographics
NPI:1285264903
Name:GONZALES, DANIEL (LCSW)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 LA SOMBRA RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6135
Mailing Address - Country:US
Mailing Address - Phone:505-720-3548
Mailing Address - Fax:
Practice Address - Street 1:1420 CARLISLE BLVD NE STE 103
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5661
Practice Address - Country:US
Practice Address - Phone:505-720-3548
Practice Address - Fax:505-554-3435
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
NM104100000X
NMC-11895104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM-10542OtherLICENSE NUMBER